Information Required to add Medicaid Facility/Agency in the Criminal History Record System

Date:

Name of Facility/Agency:

Physical Address of Facility/Agency:

City: State: Zip:

County:

Mailing Address:

City: State: Zip:

Facility/Agency Phone Number:

Facility/Agency Email:

Owner:

Email:

Facility/Agency Contact/HR Director:

Email:

Please place a check in the correct space:

____ New Facility

___ _ Change of mailing address, phone number, or contact name

_ _ __ Permanently closed or Pending file closed in database

This information is required for the Criminal History Record Check Unit to add new facilities/agencies to the Fingerprint system for background checks. Once CHRC has put the new facility/agency into our system, we will send the facility/agency contact/Human Resources Director a new facility/agency packet that includes fingerprint cards, Privacy Rights Form, and instruction sheets.

Feel free to contact Molly Chew (601-364-1101) in the CHRC Unit with any questions or concerns.